DENTAL ASSISTANT STUDENT
MEDICAL/DENTAL HISTORY
Name ___________________________________ Date of Birth __________________
Last First M.I.
Address
Street City Zip
MEDICAL ALERT
MEDICAL HISTORY
Physician _________________________________________ Office Phone
Approximate date of last physical examination ____________________________
Yes No
1. Are you under any medical treatment now? ………………………………………..
2. Have you had any major operations? If so what? ………………………………….
3. Have you ever had a serious accident involving head injuries?................................
4. Have you had any adverse response to any drugs including penicillin?...................
5. Has a physician ever informed you that you had: a heart ailment?...........................
6. high blood pressure?.......................................................
7. respiratory disease?.........................................................
8. diabetes?.........................................................................
9. rheumatic fever?..............................................................
10. rheumatism or arthritis?..................................................
11. tumors or growths?..........................................................
12. any blood disease?..........................................................
13. any kidney disease?.........................................................
14. any stomach or intestinal disease?..................................
15. any venereal disease?......................................................
16. yellow jaundice or hepatitis?...........................................
17. heart murmurs?................................................................
18. joint replacements?..........................................................
19. Do you have night sweats accompanied by weight loss or cough? ………………..
20. Are you on a diet at this time? ...................................................................................
21. Are you now taking drugs or medication? If yes, what? ...........................................
22. Are you allergic to any known materials resulting in hives, asthma, eczema, etc.?
23. Are you in generally good health at this time? ..........................................................
24. Have any wounds healed slowly or presented other complications?.........................
25. ARE YOU PREGNANT? .....................................................................................
26. Do you have a history of fainting?.............................................................................